I’m writing this Log post from Las Vegas, USA, where I have come to experience the Downtown Project, an attempt to transform the downtown area into the most community-focused large city in the world. I think it’ll take me a few days to digest what I am learning but its community focus very much reminds me of a story that lit the touch paper on Wellthcare and I thought I’d share it. Richard Smith, the Director of United Health Group’s Chronic Disease Initiative and the former Editor-in-Chief of the BMJ shared the story as a blog post. In essence, his mother has no short-term memory and he was asking, “How much have the health and social services helped my mother?” I encourage you to read the full post but this series of excerpt gives you a flavour of what he and his family were dealing with:

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short-term memory.

What immediately caught my attention was the possible role of the postman. He goes on:

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits. It was bureaucratic value that was added.

I was struck by how the patient’s preference was somehow a sideshow – she “hated it all” and yet was dragged through the system, eventually getting drugs that only had “a small chance” to do any good.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others; so no value in this.

What struck me in this is the ‘information asymmetry’ that plagues health care. Providers of care often know which services are better, even which clinicians are better than others, and yet that information is not shared. So we have a patient and her family who are not being listened to (“hated it all”), are being offered low value (drugs with only “a small chance” of working), and are having significant value withheld from them (they “know which [services] are better than others”). The story reaches a crescendo when Richard’s mother has a fall.

It had to happen. Indeed, it’s happened before. This time she has a scalp wound…my brother rings 111 [a health care advice line in England]. Risk averse, as they have to be, they recommend a visit to Accident and Emergency. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. He suggests a visit to the GP in four days’ time. I say poppycock to all this and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

It’s the possible iatrogenesis that gets me here. The health and social care system is allegedly designed to help and yet in its implementation what it’s really doing is increasing the risk of “diarrhoea through taking antibiotics”. I love how Richard ends the story.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.

I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

So where was the value to Richard, his family and his mother? In the postman and the newsagent. Now reflect on the deafening noise coming from the health innovation and health policy scenes and ask yourself who is really looking to understand and leverage this value? I’m sure it’ll be hard, but that doesn’t mean we should not try. Indeed, what options do we really have? Footnote: I got permission from both Richard Smith and the BMJ to reprint excerpts of this story. I should also declare that Richard is my mentor and someone who has both shaped my thinking and encouraged me to explore.

I hope all is well in sunny (I'm guessing) Las Vegas. The quote you ended with is exactly the sort of thing that needs to inform the discussion of value. Its precisely the sort of voice that I'm trying to get heard in the Bristol Project. You said a while ago that the focus of our two projects was fundamentally different - but Id like to see if you've modified your views at all when you are back from the States. It seems that we are both trying to look at new ways to think about value - ie not the Porter version but something broader and more holistic from a societal perspective.

I do believe our thinking is aligned. I think my previous comment about the fundamental difference was around the funding. If memory serves, you were using future health care savings as a way to justify new spend today. My view is that with ageing populations and persistent medicalisation we have no choice but to find *new* value over and above what is spent on health care.

I am well aware that it's hard to justify spending more on health care but that's only an issue if you see it solely as health care. I believe that investing in Wellthcare is, as you suggest, a way to create wider, more holistic value. I also think it needn't be handled by the health care industry (if at all), although it needs to segue to it as seamlessly as possible.

There will be many challenges to make this way of doing things a reality but I am convinced a 'coalition of the willing' is an important next step. Let's discuss this when I am back (end of November). I will email you separately about this.

Thanks for your comment and I am pleased you've shared those links again so people perusing the Wellthcare site will see aligned thinking coming from other places.

I love this sentence by the way: 'I am well aware that it's hard to justify spending more on health care but that's only an issue if you see it solely as health care.' This is a great way into a discussion about how we believe applying our collective resources in particular ways creates value - not value for money which is a concept that only works in a closed system - but value conceptualised as a something connected to those things that matter to people, not to organisations or systems. I'm looking forward to the discussion....

I look forward to hearing from you soon - enjoy the rest of your trip, David